Health inspection·July 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R2). This was identified as past non-compliance. Findings include: Review of the facility policy Elopement Preventions and Management; Unsafe Wandering and Exit Seeking Behavior dated 4/22/24, defined elopement as when a cognitively impaired resident leaves the physical structure of the facility unattended and with without staff knowledge or not within residents sight. The policy further stated that the facility will identify residents at risk for unsafe wandering and exit seeking behavior, and develop individualized prevention and management interventions based on assessment. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/14/24, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior). Review of Section C: Cognitive Patterns indicated Resident R2 had severe cognitive impairment. Review of an Elopement Observation assessment completed on 7/2/24, indicated Resident R2 was at risk for elopement. Review of Resident R2's plan of care for elopement risk initiated 10/20/23, indicated Resident R2 had a Wanderguard (security bracelet that alerts when an identified resident approaches a monitored Page 1 of 4 395695 395695 07/05/2024 Greenery Center for Rehab and Nursing 2200 Hill Church-Houston Road Canonsburg, PA 15317

F 0689 door). Level of Harm - Minimal harm or potential for actual harm Review of a physician's order dated 9/30/23, indicated for staff to check function and placement of Resident R2's Wanderguard every shift. Residents Affected - Few Review of Resident R2's Treatment Administration Record for July 2024 indicated Resident R2's Wanderguard was check for function and placement on every shift. Review of facility submitted information dated 7/5/24, indicated that on 7/4/24, at 4:45 p.m. it was noted that a resident family member was bringing Resident R2 back into the building through the main entrance. Resident R1 was seated in her wheelchair. The RN (Registered Nurse) Supervisor was notified. The RN Supervisor assessed the resident and found no change in condition. Resident R2 is alert but not oriented to place or time and has a BIMS score of 3. She has an elopement score of 6which is at risk and was ordered a Wanderguard which she had on, but the battery was not functioning. The Wanderguard was immediately replaced. On 7/4/24, the facility initiated a plan of correction that included: - Resident R2's Wanderguard was immediately replaced. - Family and physician were notified. - Resident census count was completed and there were not other residents that were not accounted for. - Audit completed of all residents with Wanderguards for placement and function. - All residents were reassessed for elopement risk. - Physicians' orders for Wanderguards were verified and placed, as appropriate. - Staff education was completed on elopement prevention and management, identifying residents at risk, and what to do during an elopement. - Audits for Wanderguard functioning will be completed by the Director of Nursing (DON)/Designee weekly. -The results of these audits will be forwarded to the facility QAPI committee for further review and recommendations. During four interviews on 7/5/24, staff confirmed they received education on elopement prevention and procedures if an elopement occurs. During an interview on 7/5/24, at approximately 3:00 p.m. the Assistant Nursing Home Administrator confirmed that the facility failed to provide adequate supervision to prevent elopement for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 395695 Page 2 of 4 395695 07/05/2024 Greenery Center for Rehab and Nursing 2200 Hill Church-Houston Road Canonsburg, PA 15317

F 0689 28 Pa. Code 201.18(b)(e)(1) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.20(b)(1) Staff development. 28 Pa. Code 201.29(a) Resident rights. Residents Affected - Few 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. 395695 Page 3 of 4 395695 07/05/2024 Greenery Center for Rehab and Nursing 2200 Hill Church-Houston Road Canonsburg, PA 15317

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined that the facility failed to provide transportation for a scheduled appointment for one of three residents (Resident R1). Residents Affected - Few Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/10/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of a physician's order dated 4/26/24, indicated that on 5/20/24, Resident R1 had an appointment at an eye doctor. Review of Resident R1's clinical record failed to include documentation that Resident R1 was taken to that appointment. Review of information submitted by Resident R1's family indicated that when she asked the facility if Resident R1 had gone to the appointment, they were unable to provide the answer. The family member stated in the information submitted that when she called the eye doctor, they confirmed with her that Resident R1 did not arrive to the appointment. Review of a progress note dated 5/31/24, at 3:26 p.m. indicated, Called [eye doctor's] office. Patient never went to eye appointment on 5/20/24. During an interview on 7/5/24, at 2:12 p.m. Registered Nurse Supervisor Employee E1 stated she spoke to the RN Supervisor at the time of the appointment and the employee who provides transportation, and she was unable to find a reason why Resident R1 did not go to his appointment. During an interview on 7/5/24, at approximately 2:30 p.m. the Assistance Nursing Home Administrator confirmed the facility failed to provide transportation for a scheduled appointment for one of three residents. 28 Pa. Code: 211.16(a) Social services. 395695 Page 4 of 4